Overactive bladder

Overview

Overactive bladder causes a sudden urge to urinate. The urge may be difficult to stop, and overactive bladder may lead to the involuntary loss of urine (urge incontinence).

If you have an overactive bladder, you may feel embarrassed, isolate yourself, or limit your work and social life. The good news is that a brief evaluation can determine whether there's a specific cause for your overactive bladder symptoms.

Management of overactive bladder often begins with behavioral strategies, such as fluid schedules, timed voiding and bladder-holding techniques using your pelvic floor. If these initial efforts don't help enough with your overactive bladder symptoms, medications are available.

Symptoms

With an overactive bladder, you may:

Feel a sudden urge to urinate that's difficult to control

Experience urge incontinence — the involuntary loss of urine immediately following an urgent need to urinate

Urinate frequently, usually eight or more times in 24 hours

Awaken two or more times in the night to urinate (nocturia)

Although you may be able to get to the toilet in time when you sense an urge to urinate, unexpected frequent urination and nighttime urination can disrupt your life.

When to see a doctor

Although it's not uncommon among older adults, overactive bladder isn't a normal part of aging. If your symptoms distress you or disrupt your life, talk to your doctor. Treatments are available that might help you.

Discussing such a private matter with your doctor might not be easy, but it's worthwhile to take that risk — especially if your symptoms disrupt your work schedule, social interactions and everyday activities.

Causes

Normal bladder function

The kidneys produce urine, which drains into your bladder. When you urinate, urine passes from your bladder through an opening at the bottom and flows out a tube called the urethra (u-REE-thruh).

In women, the urethral opening is located just above the vagina. In men, the urethral opening is at the tip of the penis.

As your bladder fills, nerve signals sent to your brain eventually trigger the need to urinate. When you urinate, nerve signals coordinate the relaxation of the pelvic floor muscles and the muscles of the urethra (urinary sphincter muscles). The muscles of the bladder tighten (contract), pushing the urine out.

Involuntary bladder contractions

Overactive bladder occurs because the muscles of the bladder start to contract involuntarily even when the volume of urine in your bladder is low. This involuntary contraction creates the urgent need to urinate.

Several conditions may contribute to signs and symptoms of overactive bladder, including:

Neurological disorders, such as stroke and multiple sclerosis

Diabetes

Medications that cause a rapid increase in urine production or require that you take them with lots of fluids

Acute urinary tract infections that can cause symptoms similar to an overactive bladder

Declining cognitive function due to aging, which may make it more difficult for your bladder to understand the signals it receives from your brain

Difficulty walking, which can lead to bladder urgency if you're unable to get to the bathroom quickly

Incomplete bladder emptying, which may lead to symptoms of overactive bladder, as you have little urine storage space left

The specific cause of an overactive bladder may be unknown.

Risk factors

As you age, you're at increased risk of developing overactive bladder. You're also at higher risk of diseases and disorders, such as enlarged prostate and diabetes, which can contribute to other problems with bladder function.

Many people with cognitive decline — for instance, after a stroke or with Alzheimer's disease — develop an overactive bladder. Incontinence that results from situations like this can be managed with fluid schedules, timed and prompted voiding, absorbent garments, and bowel programs.

Some people with an overactive bladder also have bowel control problems; tell your doctor if this is a problem for you.

Complications

Any type of incontinence can affect your overall quality of life. If your overactive bladder symptoms cause a major disruption to your life, you might also have:

Emotional distress or depression

Anxiety

Sleep disturbances and interrupted sleep cycles

Issues with sexuality

Your doctor might recommend treatment of associated conditions, to see if effective treatment of an associated condition will help with your urinary symptoms.

Some women also may have a disorder called mixed incontinence, when both urge and stress incontinence occur. Stress incontinence is the loss of urine when you exert physical stress or pressure on your bladder, such as during activities that include running or jumping. Treatment of the stress incontinence is not likely to help the overactive bladder symptoms.

Older people may have a common combination of bladder storage problems and bladder-emptying issues. The bladder may cause a lot of urgency and even incontinence, but it doesn't empty well. A specialist may be able to help you with this combination of bladder problems.

Manage chronic conditions, such as diabetes, that might contribute to overactive bladder symptoms.

Learn where your pelvic floor muscles are and then strengthen them by doing Kegel exercises — tighten (contract) muscles, hold the contraction for two seconds and relax muscles for three seconds. Work up to holding the contraction for five seconds and then 10 seconds at a time. Do three sets of 10 repetitions each day.

Diagnosis

If you have an abnormal urge to urinate, your doctor will check to make sure that you don't have an infection or blood in your urine. Your doctor may also want to make sure that you're emptying your bladder completely when you urinate.

Your doctor will look for clues that might also indicate contributing factors. The work-up will likely include a:

Medical history

Physical exam, focusing on your abdomen and genitals

Urine sample to test for infection, traces of blood or other abnormalities

Special tests

Your doctor may order a simple urodynamic test to assess the function of your bladder and its ability to empty steadily and completely. These tests usually require a referral to a specialist, and may not be necessary to make a diagnosis or begin treatment. Tests include:

Measuring urine left in the bladder. This test is important if your bladder doesn't empty completely when you urinate or experience urinary incontinence. Remaining urine (postvoid residual urine) may cause symptoms identical to an overactive bladder.

To measure residual urine after you have voided, your doctor may request an ultrasound scan of your bladder or pass a thin tube (catheter) through the urethra and into your bladder to drain and measure the remaining urine.

Measuring urine flow rate. To measure the volume and speed of your voiding, you may be asked to urinate into a uroflowmeter. This device translates the data into a graph of changes in your flow rate.

Testing bladder pressures. Cystometry measures pressure in your bladder and in the surrounding region during bladder filling. During this test, your doctor uses a thin tube (catheter) to fill your bladder slowly with warm water. Another catheter with a pressure-measuring sensor is placed in your rectum or, if you're a woman, in your vagina.

This procedure can identify whether you have involuntary muscle contractions or a stiff bladder that's not able to store urine under low pressure.

Your doctor will review the results of any tests with you and suggest a treatment strategy.

Treatment

A combination of treatment strategies may be the best approach to relieve overactive bladder symptoms.

Behavioral interventions

Behavioral interventions are the first choice in helping manage an overactive bladder. They're often effective, and they carry no side effects. Behavioral interventions may include:

Your doctor or a physical therapist can help you learn how to do Kegel exercises correctly. It may take as long as six to eight weeks before you notice a difference in your symptoms.

Healthy weight. If you're overweight, losing weight may ease symptoms. Weight loss may help if you also have stress urinary incontinence.

Scheduled toilet trips. Setting a schedule for toileting — for example, every two to four hours — gets you on track to urinate at the same times every day rather than waiting until you feel the urge to urinate.

Intermittent catheterization. Using a catheter periodically to empty your bladder completely helps your bladder do what it can't do by itself. Ask your doctor if this approach is right for you.

Absorbent pads. Wearing absorbent pads or undergarments can protect your clothing and help you avoid embarrassing incidents, which means that you won't have to limit your activities. Absorbent garments come in a variety of sizes and absorbency levels.

Bladder training. Bladder training involves training yourself to delay voiding when you feel an urge to urinate. You begin with small delays, such as 30 minutes, and gradually work your way up to urinating every three to four hours. Bladder training is possible only if you're able to tighten (contract) your pelvic floor muscles successfully.

Medications

Medications that relax the bladder can be helpful for relieving symptoms of overactive bladder and reducing episodes of urge incontinence. These drugs include:

Tolterodine (Detrol, Detrol LA)

Oxybutynin (Ditropan XL)

Oxybutynin as a skin patch (Oxytrol)

Oxybutynin gel (Gelnique, Gelnique 3%)

Trospium (Sanctura)

Solifenacin (Vesicare)

Darifenacin (Enablex)

Mirabegron (Myrbetriq)

Fesoterodine (Toviaz)

Common side effects of most of these drugs include dry eyes and dry mouth, but drinking water to quench thirst can aggravate symptoms of overactive bladder. Constipation — another potential side effect — can aggravate your bladder symptoms. Extended-release forms of these medications, including the skin patch or gel, may cause fewer side effects.

Your doctor may recommend that you suck on a piece of sugar-free candy or chew sugar-free gum to relieve dry mouth, and use eyedrops to keep your eyes moist. Over-the-counter preparations, such as Biotene products, can be helpful for long-term dry mouth. To avoid constipation, your doctor might recommend a fiber-rich diet or use of stool softeners.

Bladder injections

OnabotulinumtoxinA (ON-ah-boch-yoo-lih-num-tox-in-A), also called Botox, is a protein from the bacteria that cause botulism illness. Used in small doses directly injected into bladder tissues, this protein partially paralyzes muscles.

Clinical research shows that it may be useful for severe urge incontinence. The temporary effects generally last five months or more, but repeat injections are necessary.

About half of people had side effects from these injections, including 9 percent who had urinary retention. So, if you're considering Botox treatments, you should be willing and able to catheterize yourself if urinary retention occurs.

Nerve stimulation

One procedure uses a thin wire placed close to the sacral nerves — which carry signals to your bladder — where they pass near your tailbone.

This surgical procedure is often done with a trial of a temporary wire or as an advanced procedure in which the permanent electrode is implanted and a longer trial is performed prior to a surgical placement of the battery-powered pulse generator. Your doctor then uses a device connected to the wire to deliver electrical impulses to your bladder, similar to what a pacemaker does for the heart.

If this successfully reduces your symptoms, the wire is eventually connected to a small battery device that's placed under your skin.

Surgery

Surgery to treat overactive bladder is reserved for people with severe symptoms who don't respond to other treatments. The goal is to improve the bladder's ability to store urine and reduce pressure in the bladder. However, these procedures won't help relieve bladder pain. Interventions include:

Surgery to increase bladder capacity. This procedure uses pieces of your bowel to replace a portion of your bladder. This surgery is used only in cases of severe urge incontinence that doesn't respond to any other, more-conservative treatment measures. If you have this surgery, you may need to use a catheter intermittently for the rest of your life to empty your bladder.

Bladder removal. This procedure is used as a last resort and involves removing the bladder and surgically constructing a replacement bladder (neobladder) or an opening in the body (stoma) to attach a bag on the skin to collect urine.

Lifestyle and home remedies

These lifestyle strategies may reduce overactive bladder symptoms:

Maintain a healthy weight. If you're overweight, losing weight may ease your symptoms. Heavier people are also at greater risk of stress urinary incontinence, which may improve with weight loss.

Don't restrict fluid. Ask your doctor how much fluid you need daily. If you don't drink enough, your urine becomes concentrated and can irritate the lining of your bladder. This increases the urge to urinate.

Alternative medicine

No complementary or alternative therapies have been proved to successfully treat overactive bladder. But treatments that might be helpful include:

Biofeedback. During biofeedback, you're connected to electrical sensors that help you measure and receive information about your body. The biofeedback sensors teach you how to make subtle changes in your body, such as strengthening your pelvic muscles so that when you have feelings of urgency you're better able to suppress them.

Acupuncture. Acupuncture practitioners treat you using extremely thin, disposable needles. Research has suggested that acupuncture might help ease the symptoms of overactive bladder.

Complementary treatments may not be covered by insurance, so check with your insurance company first.

Coping and support

Living with overactive bladder can be difficult. Consumer education and advocacy support groups such as the National Association for Continence can provide you with online resources and information, connecting you with people who experience overactive bladder and urge incontinence. Support groups offer the opportunity to voice concerns, learn new coping strategies and stay motivated to maintain self-care strategies.

Educating your family and friends about overactive bladder and your experiences with it may help you establish your own support network and reduce feelings of embarrassment. Once you start talking about it, you may be surprised to learn how common this condition really is.

Preparing for an appointment

For overactive bladder, you're likely to start by seeing your primary doctor. After your initial appointment, you may be referred to a specialist in urinary disorders in men and women (urologist), a specialist in urinary disorders in women (urogynecologist), or a specialist in physical therapy for diagnosis and treatment.

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

Keep a bladder diary for a few days, recording when, how much and what kind of fluids you consume, when you urinate, whether you feel an urge to urinate, and whether you experience incontinence. A bladder diary may help determine why you have to get up to urinate at night.

Tell your doctor how long you've had your symptoms and how they affect your day-to-day activities.

Note any other symptoms you're experiencing, particularly those related to your bowel function.

Let your doctor know if you have diabetes, have a neurological disease, or have had pelvic surgery or radiation treatments.

Make a list of all the medications, vitamins or supplements you take, as many medications can affect bladder function.

Write down a list of questions to ask your doctor.

For overactive bladder, basic questions might include:

What are the possible causes of my symptoms?

Is my urine clear?

Do I empty my bladder well?

Is my pelvic floor muscle strength good enough for me to keep my bladder from contracting when I have an abnormal urge?

Do you recommend any other tests? Why?

What treatments are available, and which do you recommend for me?

What side effects can I expect from treatment?

Are there any dietary restrictions that could help?

How do my other health problems affect my bladder symptoms?

If I need to see a specialist, what can I expect?

Is there a generic alternative to the medicine you're prescribing?

Are there brochures or other printed material that I can have? What websites do you recommend?

What to expect from your doctor

Your doctor may use an overactive bladder questionnaire to make an assessment of your symptoms, asking questions such as:

How long have you had these symptoms?

Do you unexpectedly leak urine? How often?

What do your symptoms keep you from doing that you like to do?

During daily activities, such as walking or bending over, do you leak urine?